Effect of Aspirin on Cancer Chemoprevention in Japanese Patients With Type 2 Diabetes: 10-Year Observational Follow-up of a Randomized Controlled Trial

OBJECTIVE

This study analyzed the efficacy of low-dose aspirin in cancer chemoprevention in patients with diabetes.

RESEARCH DESIGN AND METHODS

This study was a posttrial follow-up of the Japanese Primary Prevention of Atherosclerosis with Aspirin for Diabetes (JPAD) trial. Participants in the JPAD trial (2,536 Japanese patients with type 2 diabetes and without preexisting cardiovascular disease) were randomly allocated to receive aspirin (81 or 100 mg daily) or no aspirin. After that trial ended in 2008, we followed up with the participants until 2015, with no attempt to change the previously assigned therapy. The primary end point was total cancer incidence. We investigated the effect of low-dose aspirin on cancer incidence.

RESULTS

During the median follow-up period of 10.7 years, a total of 318 cancers occurred. The cancer incidence was not significantly different between the aspirin and no-aspirin groups (log-rank, P = 0.4; hazard ratio [HR], 0.92; 95% CI, 0.73-1.14; P = 0.4). In subgroup analyses, aspirin did not affect cancer incidence in men, women, or participants aged ≥65 years. However, it decreased cancer incidence in participants aged <65 years (log-rank, P = 0.05; HR, 0.67; 95% CI, 0.44-0.99; P = 0.048). After adjusting for sex, hemoglobin A_1c, smoking status, and administration of metformin and statins, aspirin significantly reduced cancer incidence in participants aged <65 years (adjusted HR, 0.66; 95% CI, 0.43-0.99; P = 0.04).

CONCLUSIONS

Low-dose aspirin did not reduce cancer incidence in Japanese patients with type 2 diabetes.

Effect of Wave Reflection and Arterial Stiffness on the Risk of Development of Hypertension in Japanese Men

Background

We conducted analyses of repeated‐measures data to examine whether pressure wave reflection acts additively or synergistically with arterial stiffness in the pathogenesis of hypertension.

Methods and Results

In 3172 middle‐aged (42±9 years) healthy Japanese men without hypertension at the study baseline, systolic and diastolic blood pressures, brachial–ankle pulse wave velocity, and radial augmentation index were measured annually during a 9‐year study period. Of these, 474 participants (15%) developed hypertension by the end of the study period. Binary logistic regression analysis demonstrated significant individual odds ratios for both baseline brachial–ankle pulse wave velocity and radial augmentation index for the development of hypertension. The rate of onset of hypertension during the study period was highest in the participant group with high values for both brachial–ankle pulse wave velocity and radial augmentation index at study baseline (262 of 965 participants: 27%). The generalized estimating equation analysis revealed that both radial augmentation index (estimate=0.06, SE=0.03, P=0.05) and brachial–ankle pulse wave velocity (estimate=0.07×10⁻¹, SE=0.02×10⁻¹, P<0.01) showed significant longitudinal association with new onset of hypertension, with no significant interaction.

Conclusions

In Japanese men, abnormal wave reflection and increased arterial stiffness may be additively associated with the risk of new onset of hypertension. Abnormal wave reflection and elevated central blood pressure may be longitudinally associated with increase in arterial stiffness, and this longitudinal association may be a mechanism underlying the additive effect of these 2 variables on the risk of new onset of hypertension.

Cocoa Polyphenols: Evidence from Epidemiological Studies

Background:

Accumulating evidence suggests potential preventive effects of chocolate/cocoa on the risk of cardio vascular disease (CVD). However, cocoa products also contain high levels of sugar and fat, which increase CVD risk factors. Even, the identity of the substance in chocolate/cocoa that has a favorable effect on CVD and CVD risk factors remains unclear, growing evidence from experimental studies suggests that cocoa polyphenols might be a major contributor to cardiovascular-protective effects. However, epidemiological studies, which are necessary to evaluate an association between the risk of CVD and cocoa polyphenol, remain sparse.

Methods:

We will discuss recent evidence regarding the association between cocoa polyphenol consumption and the risks of CVD and its risk factors by reviewing recent epidemiological studies. We shall also provide some guidance for patient counseling and will discuss the public health implications for recommending cocoa polyphenol consumption to prevent CVD.

Results:

Epidemiological studies evaluating the association between cocoa polyphenol itself and the risk of CVD are sparse. However, evidence from limited epidemiological studies suggests that cocoa polyphenol consumption may lower the risk of CVD.

Conclusion:

Given the potential adverse effects of the consumption of cocoa products with high fat and sugar and the fact that the most appropriate dose of cocoa polyphenol for cardio-protective effects has not yet been established, health care providers should remain cautious about recommending cocoa/cocoa polyphenol consumption to their patients to reduce the risk of CVD, taking the characteristics of individual patients into careful consideration.

Investigation of antibody to severe fever with thrombocytopenia syndrome virus (SFTSV) in blood samples donated in a SFTS-endemic area in Japan

The risk of transfusion-transmitted infection (TTI) for severe fever with thrombocytopenia syndrome virus (SFTSV) is a concern because person-to-person transmission resulting from contact with SFTSV-contaminated blood has been reported. To obtain information regarding the risk of TTI-SFTSV, antibody testing was performed for blood samples donated in an severe fever with thrombocytopenia syndrome-endemic area in Japan. No antibody-positive samples were detected among 3990 samples. This finding suggested that there were few cases of SFTSV infection among donors and that the risk of TTI-SFTSV was also estimated low in Japan.

Longitudinal association among endothelial function, arterial stiffness and subclinical organ damage in hypertension

OBJECTIVES

To examine the longitudinal mutual association between endothelial dysfunction and arterial stiffness, and also to determine which of the two variables was more closely associated with the progression of subclinical organ damage.

METHODS

The brachial-ankle pulse wave velocity (baPWV), carotid intima-media thickness (CIMT), estimated glomerular filtration rate, microalbuminuria and flow-mediated vasodilatation of the brachial artery (FMD) were measured three times at 1.5-year intervals in 674 Japanese patients receiving antihypertensive treatment.

RESULTS

The change of the baPWV during the study period was larger in the subjects with baseline FMD values in the lowest tertile as compared to those with baseline FMD values in the highest tertile. The change of the CIMT was smaller in the subjects with baseline baPWV values in the lowest tertile than in those with baseline baPWV values in the highest tertile. After the adjustment, the FMD value at the baseline was inversely associated with the baPWV at the end of the study period (beta=-0.07, p=0.01), although, the reverse association was not significant. The baPWV, but not the FMD value, at the baseline was associated with the CIMT (beta=0.06, p=0.04) measured at the end of the study period.

CONCLUSIONS

In hypertension, endothelial dysfunction was associated with the progression of arterial stiffness, although the reverse association was not confirmed. The increased arterial stiffness rather than endothelial dysfunction may be more closely associated with the progression of atherosclerotic vascular damage, and the endothelial dysfunction-arterial stiffness-atherosclerosis continuum may be important in hypertension.

Abstract P518: Abnormal Pressure Wave Reflection Accelerates the Development of Hypertension via the Increase of Arterial Stiffness

Objectives: Arterial stiffness (macrovascular damage) and peripheral vascular damage (microvascular damage) affect pressure wave reflection, and several prospective studies have demonstrated that not only arterial stiffness but also abnormal pressure wave reflection are risks for the development of hypertension. However, the association between arterial stiffness and pressure wave reflection in the development of hypertension has not been fully clarified. The present study was conducted to examine whether the abnormal pressure wave reflection accelerates the development of hypertension via the increase of arterial stiffness.

Methods: In 3102 middle-aged healthy Japanese men without hypertension at baseline, systolic/diastolic blood pressures, brachial-ankle pulse wave velocity (baPWV), and radial augmentation index (rAI) were annually measured during a 9-year study period.

Results: In multivariate linear regression analysis and in mixed model linear regression analysis, baPWV was not longitudinally associated with rAI. Linear regression analysis demonstrated that the higher rAI at the baseline was associated with the larger longitudinal increase of baPWV (beta = 0.17, p<0.01). At the end of study period, 404 subjects were developed to hypertension. Binary logistic regression analysis demonstrated that baPWV (per SD increase = 1.43; 1.25 – 1.62, p<0.01) and rAI (per SD increase = 1.56; 1.33 – 1.82, p<0.01) at the baseline had significant odds ratio for the prediction of the development of hypertension. The prevalence rate of the development of hypertension during the study period was higher in subjects with higher baPWV and higher rAI at the baseline (220 in 939 subjects: 23 %) than that in other 3 groups classified by the status of baPWV and rAI at the baseline (e.g. 52 in 942 subjects with low baPWV combined with low rAI: 6%, p<0.01).

Conclusion: The abnormal pressure wave reflection, which may be derived from both arterial stiffness and peripheral vascular damages, may be an accelerator for the development of hypertension via the increase of arterial stiffness. In there, the combination of macro- and micro-vascular damages may accelerate the development of hypertension.

Abstract P516: Arterial Stiffness is a Mediator of Uric Acid-related Development of Hypertension

Objectives: Uric acid (UA) is a risk for the development of hypertension, but the underlying mechanisms of this development has not been fully clarified. On the other hand, arterial stiffness is also noted as a risk for the development of hypertension. Then, the present prospective observational study examined whether UA is associated with the development of hypertension mediated by the increase of arterial stiffness.

Methods and Results: In 3274 middle-aged Japanese men (aged 42 ± 9 years old) without hypertension at the study baseline, the brachial-ankle pulse wave velocity (baPWV), radial augmentation index (rAI), systolic and diastolic blood pressure (SBP/DBP) and serum UA level were measured annually over a 9-year period. During this study period, 474 subjects (14.5%) developed hypertension. Binary logistic regression analysis demonstrated that serum UA levels has a significant odds ratio for the development of hypertension even after the adjustment [1.3 (1.1-1.5), p<0.01]. Multivariate linear regression analysis also demonstrated that serum UA levels at the baseline of study period had a significant association with delta changes of SBP (beta=0.10 p<0.01), DBP (beta = 0.13, p<0.01) and baPWV (beta=1.12 p<0.01), but not that of rAI, during the study period. Mixed model linear regression analysis in repeated measurement data revealed the following: 1) At each annual measurement, higher serum UA levels were associated with a higher annual increase of the SBP (estimate=0.63 p<0.01), DBP (estimate=0.63 p<0.01) and baPWV (estimate=6.70 p<0.01). Mediation analysis demonstrated that baPWV had a significant indirect effect on the association of UA at the baseline with the delta change of SBP (indirect effect = 0.03 p<0.01).

Conclusion: UA is a risk for the development of hypertension. In there, UA may elevate blood pressure via increase in arterial stiffness, at least in parts.

Abstract P514: Age-related Differences in the Annual Changes of the Ankle-brachial Pressure Index: Underlying Mechanisms

Objectives: The present prospective observational study was conducted to examine the age-related annual changes of the ankle-brachial pressure index (ABI) and their association with the longitudinal changes of the brachial-ankle pulse wave velocity (baPWV), a marker of arterial stiffness, and the radial augmentation index (rAI), a marker of the pressure wave reflection in middle-aged Japanese men.

Methods and Results: In 4264 men (42 ± 9 years old) of a Japanese construction company, the ABI, baPWV and rAI were measured annually over a 9-year observation period. During the study period, ABI (from 1.10 ± 0.07 to 1.13 ± 0.07), baPWV (from 1295 ± 194 to 1344 ± 217 cm/sec) and rAI (from 69 ± 13 to 72 ± 13 %) were increased significantly (p<0.01). Mixed model linear regression analysis of the repeated-measures data revealed that the annual increase of the ABI was lower in men aged over 50 years of age (n = 1237: 0.28 ± 0.06) than in those aged under 50 years of age (n = 3027: 0.50 ± 0.04) (p < 0.01). Furthermore, while increased baPWV (estimate = 0.017, p < 0.05) and increased rAI (estimate 0.254, p < 0.05) were significantly related to the annual increase of the ABI in men aged <50 years (p < 0.01), no such association was observed in men aged > 50 years.

Conclusion: In middle-aged Japanese men, the ABI increases with age until the age of 50 years, and increased arterial stiffness and increased pressure wave reflection may contribute to this annual increase. In men aged > 50 years, the annual increase of the ABI was attenuated, which could be related, at least in part, to the attenuation of the increase of the pressure wave reflection and also attenuation of the effect of increased arterial stiffness on the hydrostatic pressure in the arteries with age. These findings may suggest the usefulness of ABI measurement as a screening tool for peripheral arterial disease in men over 50 years old.

Differences in Adverse Drug Events Among Pediatric Patients With and Without Cancer: Sub-Analysis of a Retrospective Cohort Study

Objectives

This study investigated the differences in the incidence and severity of adverse drug events (ADEs) in pediatric patients with and without cancer.

Methods

We used data from the Japan Adverse Drug Events Study for pediatrics, a cohort study enrolling pediatric inpatients at two tertiary care teaching hospitals in Japan. ADEs were identified by on-site review of all medical charts, incident reports, and prescription queries by pharmacists. Two independent physicians reviewed all potential ADEs and classified ADEs in terms of severity and class of causative medication. We compared the incidence and characteristics of ADEs between pediatric cancer patients and non-cancer patients.

Results

We enrolled 1189 patients during the study period, 27 with cancer and 1162 without cancer. We identified 480 ADEs in 234 patients (20%): 191 ADEs among 21 cancer patients and 289 ADEs among 213 non-cancer patients (7.1 per patient vs. 0.25 per patient, respectively; p < 0.0001). The most common medications associated with ADEs in cancer patients were antitumor agents; in contrast, medications associated with fatal or life-threatening ADEs in cancer patients were most often sedatives (25%) and blood products (25%). Medications associated with fatal or life-threatening ADEs among non-cancer patients were most often sedatives (15%). The percentages of fatal or life-threatening ADEs in cancer patients and non-cancer patients were 2.1 and 4.5%, respectively.

Conclusions

Pediatric patients with cancer have a higher risk for ADEs. Although the overall severity was similar between patients with and without cancer, the most common classes of causative medication and medications associated with a higher rate of severe ADEs differed. Application of this information may help minimize the impact of ADEs in pediatric patients.

Associations of Diabetes and Obesity with Risk of Abdominal Aortic Aneurysm in Men

Background. The associations of diabetes and obesity with the risk of abdominal aortic aneurysm (AAA) are inconclusive in previous studies. Subjects/Methods. We conducted prospective analysis in the Physicians' Health Study. Among 25,554 male physicians aged ≥ 50 years who reported no AAA at baseline, 471 reported a newly diagnosed AAA during a mean of 10.4 years' follow-up. Results. Compared with men who had baseline body mass index (BMI) < 25 kg/m², the multivariable hazard ratio (HR [95% CI]) of newly diagnosed AAA was 1.30 [1.06-1.59] for BMI 25-<30 kg/m² and 1.69 [1.24-2.30] for BMI ≥ 30 kg/m². The risk of diagnosed AAA was significantly higher by 6% with each unit increase in baseline BMI. This association was consistent regardless of the other known AAA risk factors and preexisting vascular diseases. Overall, baseline history of diabetes tended to be associated with a lower risk of diagnosed AAA (HR = 0.79 [0.57-1.11]); this association appeared to vary by follow-up time (HR = 1.56 and 0.63 during ≤ and >2 years' follow-up, resp.). Conclusion. In a large cohort of middle-aged and older men, obesity was associated with a higher risk, while history of diabetes tended to associate with a lower risk of diagnosed AAA, particularly over longer follow-up.

Traditional Cardiovascular Risk Factors for Incident Atrial Fibrillation

To prevent atrial fibrillation (AF), it is essential to reduce its risk factors and extend healthy life expectancy as a result. There are few reviews on the AF risk factors. We discuss them and approach the prevention of AF. We briefly review traditional risk factors for incident AF, especially focusing on high blood pressure, overweight/obesity, dyslipidemia, diabetes, tobacco smoking, and excessive drinking. When trying to prevent AF by modifying lifestyle, it is important to comprehensively utilize the risk factors for AF to predict the 10-year as an AF risk score. However, there are only 2 risk scores of AF just for the US population. There are few studies of the AF risk factors in non-Western populations. A risk score for incident AF in non-Westerners is awaited because different race and lifestyles may have different contributions as AF risk factors. An AF risk score in accordance with race could be useful for identifying persons with a high risk of AF in order to encourage them to consult a doctor and encourage lifestyle modifications before the onset of AF. (Circ J 2016; 80: 2415-2422).

ω-3 Polyunsaturated Fatty Acid Biomarkers and Coronary Heart Disease: Pooling Project of 19 Cohort Studies

IMPORTANCE

The role of ω-3 polyunsaturated fatty acids for primary prevention of coronary heart disease (CHD) remains controversial. Most prior longitudinal studies evaluated self-reported consumption rather than biomarkers.

OBJECTIVE

To evaluate biomarkers of seafood-derived eicosapentaenoic acid (EPA; 20:5ω-3), docosapentaenoic acid (DPA; 22:5ω-3), and docosahexaenoic acid (DHA; 22:6ω-3) and plant-derived α-linolenic acid (ALA; 18:3ω-3) for incident CHD.

DATA SOURCES

A global consortium of 19 studies identified by November 2014.

STUDY SELECTION

Available prospective (cohort, nested case-control) or retrospective studies with circulating or tissue ω-3 biomarkers and ascertained CHD.

DATA EXTRACTION AND SYNTHESIS

Each study conducted standardized, individual-level analysis using harmonized models, exposures, outcomes, and covariates. Findings were centrally pooled using random-effects meta-analysis. Heterogeneity was examined by age, sex, race, diabetes, statins, aspirin, ω-6 levels, and FADS desaturase genes.

MAIN OUTCOMES AND MEASURES

Incident total CHD, fatal CHD, and nonfatal myocardial infarction (MI).

RESULTS

The 19 studies comprised 16 countries, 45 637 unique individuals, and 7973 total CHD, 2781 fatal CHD, and 7157 nonfatal MI events, with ω-3 measures in total plasma, phospholipids, cholesterol esters, and adipose tissue. Median age at baseline was 59 years (range, 18-97 years), and 28 660 (62.8%) were male. In continuous (per 1-SD increase) multivariable-adjusted analyses, the ω-3 biomarkers ALA, DPA, and DHA were associated with a lower risk of fatal CHD, with relative risks (RRs) of 0.91 (95% CI, 0.84-0.98) for ALA, 0.90 (95% CI, 0.85-0.96) for DPA, and 0.90 (95% CI, 0.84-0.96) for DHA. Although DPA was associated with a lower risk of total CHD (RR, 0.94; 95% CI, 0.90-0.99), ALA (RR, 1.00; 95% CI, 0.95-1.05), EPA (RR, 0.94; 95% CI, 0.87-1.02), and DHA (RR, 0.95; 95% CI, 0.91-1.00) were not. Significant associations with nonfatal MI were not evident. Associations appeared generally stronger in phospholipids and total plasma. Restricted cubic splines did not identify evidence of nonlinearity in dose responses.

CONCLUSIONS AND RELEVANCE

On the basis of available studies of free-living populations globally, biomarker concentrations of seafood and plant-derived ω-3 fatty acids are associated with a modestly lower incidence of fatal CHD.

Obstructive Sleep Apnea as Possible Causal Factor for Visit-to-Visit Blood Pressure Variability

BACKGROUND

Recent studies have shown that visit-to-visit blood pressure variability (BPV) is an independent risk factor for cardiovascular disease. However, it has not been clarified whether obstructive sleep apnea (OSA) is associated with visit-to-visit BPV.

METHODS AND RESULTS

The 56 subjects with OSA and 26 control subjects without OSA were examined. Office BP was measured on 5 separate consecutive occasions prior to a polysomnography examination. The visit-to-visit BPV was expressed as the standard deviation and the coefficient of variation of the 5 systolic BP measurements. In subjects with an apnea-hypopnea index (AHI) of more than 20 episodes per hour, the visit-to-visit BPV was also measured after the start of continuous positive airway pressure (CPAP) therapy. Overall, the AHI positively correlated with the standard deviation and the coefficient of variation of systolic BP. In a multivariate analysis, the plasma noradrenaline level and the AHI were independently and positively correlated with the standard deviation and the coefficient of variation of the systolic BP. Among the patients who underwent CPAP therapy, good adherence with CPAP therapy significantly reduced the visit-to-visit BPV.

CONCLUSIONS

OSA is associated with abnormal visit-to-visit BPV and sympathetic activation seems to be related in some way. (Circ J 2016; 80: 1787-1794).

Hypertension Is a Risk Factor for Several Types of Heart Disease: Review of Prospective Studies

Many prospective cohort studies have demonstrated that hypertension is a strong risk factor for total mortality and cardiovascular disease (CVD). Heart disease includes coronary heart disease (CHD), heart failure, atrial fibrillation, valvular disease, sudden cardiac death (SCD), sick sinus syndrome (SSS), cardiomyopathy, and aortic aneurysms. Most of the epidemiologic prospective studies of heart disease focused on coronary/ischemic heart disease. Here we comprehensively reviewed the association between hypertension and the above-mentioned heart diseases. We found that CHD, heart failure, atrial fibrillation, aortic valvular disease, SCD, SSS, left ventricular hypertrophy, and abdominal aortic aneurysms were all associated with hypertension. Those relations tended to be stronger in men. The prevention of hypertension and lowering one's blood pressure may help reduce the risk of developing heart disease.

Efficacy of the Mirasol pathogen reduction technology system against severe fever with thrombocytopenia syndrome virus (SFTSV)

Severe fever with thrombocytopenia syndrome virus (SFTSV) is a tickborne virus in the Bunyaviridae family. This virus has recently been found in China, Japan and Korea. The risk of transfusion-transmitted SFTSV infection (TTI-SFTSV) is a concern because person-to-person transmission resulting from contact with SFTSV-contaminated blood has been reported. Therefore, we investigated the efficacy of the Mirasol pathogen reduction technology (PRT) system for inactivating SFTSV in vitro. The Mirasol PRT system achieved a > 4.11 log10 reduction value (LRV) for SFTSV. In conclusion, we showed that the Mirasol PRT system could potentially be used to reduce the risk of TTI-SFTSV.

Estimation of the infectious viral load required for transfusion-transmitted human T-lymphotropic virus type 1 infection (TT-HTLV-1) and of the effectiveness of leukocyte reduction in preventing TT-HTLV-1

BACKGROUND AND OBJECTIVES

The risk of transfusion-transmitted human T-lymphotropic virus type 1 infection (TT-HTLV-1) after prestorage leucocyte reduction (LR) remains unknown, as the proviral load in the blood component that would cause TT-HTLV-1 is undetermined. On the basis of the distribution of HTLV-1 proviral load among HTLV-1-sero-positive blood donors, we attempted to estimate the proviral load for transfusion-related infectivity. We also discuss the effectiveness of LR in preventing TT-HTLV-1.

MATERIALS AND METHODS

The HTLV-1 proviral load in 300 HTLV-1-sero-positive blood donors was determined by real-time polymerase chain reaction analysis. The proviral load required for transfusion-related infectivity was estimated using historical TT-HTLV-1 frequency data from a retrospective study on patients who had received blood from HTLV-1-sero-positive blood donors and the distribution pattern of HTLV-1 proviral load among blood donors.

RESULTS

HTLV-1 proviral loads ranged between < 0.01 and 25.0 copies per 100 leucocytes. Historical data showed TT-HTLV-1 frequency to be 80%. Assuming that 80% of the 300 sero-positive samples are infectious, it is estimated that the transfer of ≥ 9 × 10(4) cells containing the HTLV-1 provirus is required to establish TT-HTLV-1.

CONCLUSION

The residual number of HTLV-1-infected cells after LR is substantially lower than the viral load necessary for TT-HTLV-1. LR therefore appears to be effective in minimizing the incidence of TT-HTLV-1.

Longitudinal changes in late systolic cardiac load and serum NT-proBNP levels in healthy middle-aged Japanese men

BACKGROUND

We determined whether any significant association exists between change in late systolic cardiac load with time, estimated by radial pressure waveform analysis, and development of cardiac hemodynamic stress in individuals with preserved cardiac function.

METHODS

Brachial-ankle pulse wave velocity, radial augmentation index (rAI), first peak of the radial pressure waveform (SP1), systolic and pulse pressure at the second peak of the radial pressure waveform (SP2 and PP2), and serum levels of N-terminal fragment B-type natriuretic peptide (NT-proBNP) were measured at the start (first examination) and at the end (second examination) of this 3-year study in healthy Japanese men (n = 1,851).

RESULTS

A stepwise multivariate linear regression analysis demonstrated that among the parameters of radial pressure waveform analysis and markers of arterial stiffness analyzed, only PP2 was significantly associated with serum NT-proBNP levels in study participants at both the first and second examinations. Furthermore, among the parameters analyzed, only change in PP2 was significantly correlated with the change in serum NT-proBNP levels during the study period (beta = 0.131, P < 0.001).

CONCLUSIONS

Sustained late systolic cardiac load might be a more significant determinant of the development of cardiac hemodynamic stress than sustained early systolic cardiac load or arterial stiffening in individuals with preserved cardiac function.